Abstract
Lesbians are members of a stigmatised minority group in contemporary culture and because of this it has been suggested that they have particular mental health needs [1–3]. This is supported by studies finding high rates of affective disorder, substance abuse and suicidal behaviour in this group [4]. Lesbians suffering severe chronic mental illnesses such as schizophrenia may face the burden of dual stigma as well as significant disability [5]. Despite calls for more investigation of the mental health of lesbians, few studies have been undertaken [6],[7].
Method
Sampling
Defining a ‘lesbian’ or ‘the lesbian community’ remains a controversial issue [8] and was beyond the scope of this study. Rothblum describes sexual orientation as multidimensional, claiming that ‘sexual identity (I am a lesbian), sexual behaviour (I have sex with women), and community participation (I am a member of the lesbian community) may be congruent or incongruent’ [7]. The aim of this survey was to reach as wide a range of lesbian women as possible, regardless of whether each of the dimensions of sexual orientation were congruent for them as individuals. By distributing the Lesbian Mental Health Survey (LMHS) questionnaire through lesbian newsletters and addressing the accompanying letter to lesbians, it was presumed that women who filled in the questionnaire at least associated with lesbian communities, and most likely had a sexual preference for women.
Obtaining a representative sample of a marginalised group, such as lesbian women, is always a challenge. Members of the group have a stigmatised, non-public identity and are similar in this respect to illicit drug users, meaning that, for research, similar sampling methods can be used. In this case purposeful sampling via newsletters was chosen. The Country Lesbian Mailing List and nine lesbian magazines throughout New Zealand, in both rural and urban areas, agreed to include the questionnaire with one of their mailouts and were supplied enough questionnaires to send to all the women on their subscription lists. The Country Lesbian Mailing List focuses on rural and older lesbians who might not be reached by other means.
Data collection
Questionnaires were sent out with the newsletters and returned over a 6-month period. The questionnaire included demographic information, questions on sexual orientation, the General Health Questionnaire (GHQ-28) [9], social support (Interview Schedule for Social Interaction, ISSI) [10], alcohol and drug use [11], sexual abuse, mental health service use and psychiatric history.
Analysis
Data were analysed within Epi-Info (CDC, Atlanta, USA; WHO, Geneva, Switzerland). Seven questions required text responses, the content of which was sorted into themes. The number of responses within each theme was then calculated.
The project was approved by the local Ethics Committee.
Results
Of 1222 questionnaires distributed, 561 completed questionnaires were returned, giving a response rate of 45.9%%. Some respondents subscribed to more than one lesbian newsletter. On the basis of the number of magazines subscribed to by respondents, it was estimated that 1074 women had received questionnaire forms. This derived denominator gives an estimated response rate of 50.8%%. The age range of respondents was 19–66 years, with the majority (84.2%%) in the 25–50 years age group. Most were New Zealand European (87.5%%). The ethnicity of other respondents included Maori (7.1%%), British (2.4%%), Australian (1.6%%) and Pacific Island ethnicities (less than 1%%). Two-thirds of respondents (62.2%%) had never married and a similar proportion had no children (65.5%%). Respondents were predominantly urban dwellers, with 68.8%% living in one of the six major urban centres of New Zealand. Nearly 70%% had tertiary education, in that 40.8%% had one or more university qualification and 28.5%% had other tertiary qualifications. Three-quarters (74.5%%) were in some form of paid employment, part-time or full-time. The median sole income range for respondents was $20 000 to $29 999 per annum.
Sexual orientation and identity
Nearly all (95.2%%) the respondents defined themselves as lesbian. The others defined themselves as bisexual or were non-identifying. There were no differences between those who defined themselves as lesbian and those who defined themselves in other ways, in terms of GHQ score, social support, substance abuse, history of sexual abuse, use and/or experience of mental health services. The majority of the respondents (79.3%%) had privately identified with their sexual orientation for over 5 years and 18.2%% had done so for 21 years or more.
On a Likert scale of 1 (fully accept) and 5 (do not accept), 73.8%% of the respondents scored 1, fully accepting their sexual orientation. An even higher proportion of respondents (79.5%%) said that they were very happy (scoring 1 on a scale of 1 (very happy) to 5 (unhappy) about their sexual orientation). Using a similar scale 1 (easy) to 5 (difficult), women were asked to rate their ‘coming out’ process, that is, their development of private and public lesbian identity. Approximately 20%% of respondents rated their coming out process at each score, suggesting a range of coming out experiences. The degree to which women were open about their sexual orientation varied with the situation. On a scale of 1 (everyone knows) to 5 (nobody knows), the majority of respondents indicated that most people among their close friends, in their living environment and in their family of origin knew about their lesbian identity. Mean scores for each group of people were 1.2 (95%% CI = 1.2–1.3), 1.4 (95%% CI = 1.3–1.5) and 1.9 (95%% CI = 1.8–2.0) respectively. Respondents' identity was less widely known at their workplace, among acquaintances and at places of education, with mean scores for these of 2.5 (95%% CI = 2.4–2.6), 2.5 (95%% CI = 2.4–2.6) and 2.8 (95%% CI = 2.6–2.9) respectively.
Mental health
The data on alcohol and other substance use have been reported elsewhere [12].
History of mental illness and suicide attempts
One hundred and twenty-eight (22.8%%, n = 561) respondents said they had been diagnosed with a mental illness. Of these, 117 (20.9%%) said they had been diagnosed with depression. Thirty-two women (5.7%%) said they had had eating disorders; 17 (3.0%%) said they had been diagnosed with psychosis or schizophrenia; 16 (2.9%%) said they had been diagnosed with phobias; and 23 (4.1%%) said they had had other diagnoses of mental illnesses. Half the respondents (52.9%% n = 561) said they had had serious thoughts about attempting suicide and 114 respondents (20.3%%) said they had tried to take their life at some time. Of those who had attempted suicide, 92 (80.7%% of n = 114) had done this before the age of 25.
Childhood sexual abuse
Over half the respondents (316 women, 56.3%%) said they had had an unwanted sexual experience before the age of 16. These women were then asked about specific abusive experiences prior to the age of 16. Nearly two-thirds (346 women, 61.7%%) of respondents answered affirmatively to one or more of these questions. Of the unwanted sexual experiences the most common (48.0%%) was ‘anyone older or bigger than you touching your genitals when you didn't want them to’. Three hundred and twenty-eight respondents answered the question about the gender of the person(s) involved in their abuse. Of these, 87.5%% had been abused by males but only 2.7%% had been abused by females. A further 30 women (9.1%%) had been sexually abused by both males and females. The remaining two women did not specify the gender of the perpetrator. Those women who had been sexually abused in childhood were more likely to have lower educational qualifications [Relative risk (RR) = 1.44, 95%% CI = 1.09–1.92] and be in a lower income group than those women who had not. Similarly, women who had experienced childhood sexual abuse were also more likely to report having been diagnosed with some form of mental illness (RR = 2.02, 95%% CI = 1.39–2.92).
Adulthood sexual abuse
Just over half the women (56.1%%, 315 women) said they had had an unwanted sexual experience since the age of 16. A total of 359 women (64.0%%) had been victims of one or more specific sorts of unwanted sexual activity. Of these sorts of activities, women had most commonly experienced unwanted intercourse or attempted intercourse. The question about the sex of the abuser was answered by 357 women. Of those 298 (83.5%% n = 357) women had been abused by males and 15 (4.2%% n = 357) had been abused by females. Forty-four women (12.3%% n = 357) had been abused by both males and females.
Women who had experienced unwanted sexual activity prior to age 16 were more likely to have experienced sexual abuse as adults (RR = 1.58, 95%% CI = 1.34–1.86) than women not abused as children.
Current mental health
Current mental health was assessed with the GHQ-28. A total of 558 respondents completed the GHQ. The mean score was 5.8 (95%% CI = 5.2–6.3) and the median score was 3.0, with 43.6%% of the sample scoring 5 or greater, a commonly accepted cut off score for ‘caseness’ in community samples [13].
General Health Questionnaire scores varied with a range of demographic variables, duration of being ‘out’, experience of sexual abuse and quality of social networks. Respondents were more likely to have low GHQ scores if they had a paid job than if they did not (Mann-Whitney U = 5.13, df = 1, p = 0.023). Older respondents (35 years and older), were more likely to have lower GHQ scores than younger respondents (15–34 years) (Kruskal-Wallis H = 10.73, df = 3, p = 0.013). Respondents who lived with their partner were more likely to have lower GHQ scores than women who did not live with a partner (Mann–Whitney U = 4.87, df = 1, p = 0.027).
Women who had identified with their sexual orientation for longer periods of time were more likely to have lower GHQ scores than those who had more recently identified with their sexual orientation (Kruskal-Wallis H = 19.08, df = 6, p = 0.004).
Women who had been sexually abused (either in childhood or in adulthood) were more likely to have high GHQ scores. For respondents who had been sexually abused before the age of 16, the median GHQ score was 4 compared with the median score of 2 for women who had not been abused (Mann-Whitney U = 9.36, df = 1, p = 0.002). For respondents who had been abused as an adult the median GHQ score was 5 and for those who had not the median GHQ score was 2 (Mann-Whitney U = 21.60, df = 1, p < 0.001).
Interview Schedule for Social Interaction (ISSI) and General Health Questionnaire (GHQ) scores
Mental health services
Mental health service usea
Nearly all (89.7%%) the women who had used mental health services reported that their last service provider had been aware of their sexual orientation. Of these women, 91.5%% said that the service providers were ‘lesbian friendly’ and only 3.5%% of respondents said they were not. Those who described service providers as ‘lesbian friendly’ were more likely to rate the service as being useful (Kruskal-Wallis H = 48.7, df = 2, p < 0.001).
Types of discriminatory treatment
Suggestions as to how mental health services might be improved for lesbian clients fell into three main categories. First, it was felt that mental health services should offer lesbian-friendly services such as lesbian support groups, lesbian- or women-only space, displaying posters and pamphlets aimed at lesbians and, if available, offer the services of lesbian counsellors. Second, mental health professionals should be given training about issues of sexuality and sexual orientation. Finally, it was thought that there should be more lesbian mental health practitioners available and services should make efforts to recruit, train and employ more lesbians.
Discussion
This study is the first to describe systematically the mental health of lesbians in New Zealand and their experiences of mental health services. The low response rate (50.8%%) is expected in a mail questionnaire study of this nature. As with any population study, the ideal is that our sample emulates the population from which it derives (lesbian women in New Zealand) as closely as possible [14]. In this case it was almost impossible to determine the characteristics of non-respondents. However, we know that our respondent group differed from the general population of New Zealand women in that our respondents had a higher mean age, were better educated and had a higher frequency of employment [15]. These findings are congruent with other studies of lesbians [4].
Whether this is representative of lesbian communities is not known. Such findings may simply represent a consistent selection bias in surveys of lesbian women. Alternatively, there may be real differences in age, education and employment compared with the general population of women. It may be that to be able to participate in lesbian communities, women need a degree of economic independence and exposure to different lifestyles, characteristics which may be associated with higher educational attainment or income. While women of all demographic groups may have sex with women, it is possible that only women from particular demographic groups identify with the lesbian identity and/or community, and it is this group who are practicable to sample.
Mental health
In the Christchurch psychiatric epidemiological study nearly one-fifth (19.4%%) of those surveyed were found to have an affective disorder [16]. It is interesting to note that a similar proportion (20.9%%) of our respondents said they had been diagnosed with ‘depression’ in the past. However, the two studies are difficult to compare because of their different methods, and reported proportions of other mental health problems in the current study were not similar to the proportions found in the Christchurch study.
For current mental health, the mean GHQ score of the respondent group (5.97) was higher than that of the mean score of respondents of a population survey of New Zealand women, the Otago Women's Health Survey (OWHS) [17] indicating a higher prevalence of probable psychiatric morbidity. In the general population, both a high level of education and the absence of children were associated with higher GHQ scores [17] and, as the LMHS sample in the current study was comparatively highly educated and a large proportion had no children, these factors may have contributed to the higher scores. However, the LMHS respondent group were mainly from an age range within which the OWHS found lower GHQ scores. However, given that the LMHS respondent group were mainly from an age range within which the OWHS found lower GHQ scores, we might have expected a similar pattern in the current study.
Interestingly, the mean GHQ score of the LMHS respondents was similar to the mean score of the group of women who responded to the OWHS survey who were divorced or lived in
When comparing surveys of the general population of women, like the OWHS survey, with the LMHS survey, it must be remembered that such surveys are not usually restricted to heterosexual women. Women described as divorced, single or in
An unexpected finding of the LMHS survey was that a higher proportion of the respondent group were sexually abused, either as children or adults, than reported proportions of the general population of New Zealand women. The OWHS found that 32%% of their sample were abused before the age of 16, which is similar to international figures of child sexual abuse which range from 7 to 36%% [18],[19]. We found no other studies demonstrating such high rates of sexual abuse in lesbians compared with other women. The association between past sexual abuse and poorer present mental health was also demonstrated in the OWHS [18]. The LMHS sample consisted of a high proportion of women who had been sexually abused in the past and were subsequently suffering poorer mental health status, this could have contributed to the high GHQ mean score of the whole group, as the GHQ scores of women who had been sexually abused were on average higher than scores of women who had not been abused.
Suicide
Estimates of lifetime prevalence of suicide attempts are variable, ranging from 1 to 20%% [20]. Hospital discharges of women who had attempted suicide were 0.1%% of all women in New Zealand in 1994 [21], but this is clearly an underestimate of the prevalence of suicide attempts. In the LMHS, 20.3%% of the respondent group said they had at some stage attempted to take their own life. This is in the upper bounds of international estimated prevalences of suicidal behaviour, and is close to a large study of lesbians in the USA which found 18%% of a sample of lesbians had attempted suicide [22]. Other surveys of lesbians have found similarly high reported rates of attempted suicide [4],[23]. These findings might suggest that being lesbian is a risk factor for attempted suicide. There have been no New Zealand studies asking similar questions of women about past suicide attempts and so comparison between the LMHS respondent group and the general population of New Zealand women is not possible. As New Zealand has a high rate of youth suicide and suicide attempts [24], it is possible that the general population of New Zealand women has similar attempted suicide rates to that of the LMHS respondents. Investigation of risk factors for suicide in New Zealand has not found that sexual orientation is a factor [25]. However, our finding that 80%% of those who had attempted suicide had done so prior to the age of 25 supports claims that suicide attempts are more frequent during adolescence and ‘coming out’ [26]. Possible explanations for this discrepancy include investigators failing to ask appropriate questions after completed suicides, relatives of completed suicides not being aware of sexuality problems for that person or sexual orientation not being a risk factor for suicide (i.e. ours is a chance finding).
Mental health services
We found that, compared with New Zealand women in general, a high proportion of respondents had used mental health services at some time in the past. This parallels similar findings in the USA [4],[27]. These findings give some support to the hypothesis that lesbian culture promotes the use of mental health professionals [28] and values the acknowledgement of the emotional suffering which may be inherent in developing a mature lesbian identity [27]. The finding that a large proportion of respondents found their mental health service through friendship or women's networks gives further weight to this proposal.
Nearly 30%% of respondents who had used mental health services had experienced treatment which they felt to be discriminatory. This suggests that there are still significant numbers of services providing substandard treatment to some of their clients. New Zealand's Human Rights legislation means that refusal to provide services to a lesbian is much less likely to occur than previously. However, more subtle forms of discrimination, such as simply assuming that all clients or patients are heterosexual, very likely still occur [8],[29].
Lapsley suggests that as the knowledge base on lesbian mental health issues is becoming more extensive, ‘there is no excuse for ignorance on the part of mental health professionals’ [8]. However, there is still little to be found in psychiatric journals and either general medical training or psychiatric training [30]. In light of the potential harm that treatment by anti-lesbian or homophobic professionals may cause [30],[31], we strongly recommend that material about sexuality and sexual orientation be incorporated into the basic training for all health professionals, and that training for mental health professionals, psychiatrists included, has a specific focus on knowledge of the spectrum of human sexuality and sexual orientation, and on attitudes towards people who are not heterosexual. Some of the anti-lesbian treatment described arose not from direct homophobia but from failure to acknowledge or understand a lesbian's sexuality and the life issues generated by it. Particular issues can include mourning the loss of a partner, problems with extended family, violence within relationships, conflict over degree of disclosure of sexuality, legal rights of partners [29] and the relevance of particular attachment styles to lesbians [32]. Such ignorance can be remedied if suitable training is provided. Training about these matters can be effective in changing homophobic attitudes [33],[34].
This research project has been a preliminary step in the exploration of the mental health of lesbians in New Zealand. Issues that warrant more detailed exploration include the ascertainment of the nature of the risk of suicide or parasuicidal behaviour conferred by being lesbian and, if there is such a relationship, how ‘coming out’ affects this. The relationships between sexual abuse and lesbian sexual orientation also need exploration. In addition, although mental health services are now well aware of the need to be sensitive to ethnic differences, it is clear that there is still work to do with respect to awareness of sexualities and associated lifestyles.
Footnotes
Acknowledgements
Sarah Welch was supported by a Health Research Council Studentship. We are grateful to those who took the time to respond to the survey.